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Intersection of COVID-19, Cancer, and 
Racial Health Disparities 
Linda S. Behar-Horenstein*1,4, Keesha Powell-Roach 2,4, Staja Q. Booker 2,4., Michael U. Maduka 3,4, Destiny 
Gordon2,4. Kayanna Jacobs3,8, Debra E. Lyon 2,4.  
 
1Colleges of Education, 2Nursing, and 3Medicine, University of Florida, Gainesville, FL, USA,  4Florida-
California Cancer Research, Education and Engagement (CaRE2), Health Equity Center. 

*Corresponding author and email:  Linda S. Behar-Horenstein; Lsbhoren@ufl.edu 

ABSTRACT 
In this article, we explore the intersection between the COVID-19 pandemic with cancer and the health 
disparities experienced by African Americans. Using extant literature and contemporaneous data, they 
point out how overlooking the intersections of this triad could lead to the exacerbation of existing 
disparities for cancer patients based on race and ethnicity. They suggest best practices to balance 
cancer treatment and survivorship with increasing the potential COVID-19 exposures for patients, 
families, and health care workers. Drawing upon their analysis, the authors offer a list of 
recommendations and strategies for system level responses that are designed to foster practice and 
policy for cancer care health care equity and relate to cancer care equity, infection prevention and 
control, and cancer pain management, that may reduce disparities among African Americans. 

KEYWORDS: COVID-19; cancer, health disparities; African Americans. 

Citation: Behar-Horenstein LS et al (2021) Intersection of COVID-19, Cancer, and Racial Health Disparities. 
Cancer Health Disparities. 5:e1-10.doi:10.9777/chd.2020.1007 
 
 
  



 
 
 
 
 

 
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Introduction  
The novel coronavirus (COVID-19) has caused 
untold disruption to conceptions of normative 
daily living and profound distress to the well-being 
of the world’s population. Although whether or 
not COVID-19 was a pandemic was bitterly 
debated as recently as late February 2020, in the 
United States alone there are now over four 
million cases of COVID-19. This crisis, characterized 
by the uncontrollable transmission of disease 
through a population, with differential effects on 
subpopulations at higher risk meets the criteria for 
a once in a century pandemic. [1] Compared with 
the Severe Acute Respiratory Syndrome (SARS) 
and Middle East Respiratory Syndrome (MERS) 
outbreaks, COVID-19 has spread much faster due 
to increased globalization and adaptation of the 
virus to multiple environments. [2] Its widespread 
incidence and rates of intensive care 
hospitalizations has strained the health care 
system, as well as the social and economic 
foundation of society. Other recent pandemics, 
such as the 2009 H1N1 (swine flu) pandemic 
caused concern and led to uncertainty, however 
the scale of its spread and consequent societal 
disruption was less notable. Early April of 2009 in 
Mexico, H1N1 first appeared. Within 3 months, it 
was reported in every country. By October 11, 
2009, close to 400,000 laboratory-
identified H1N1 influenza cases and >4735 deaths 
had been reported to the World Health 
Organization. [3] In comparison, and as reported 
by the Coronavirus Resource Center at Johns 
Hopkins University, there are more than 33 million 
reported COVID-19 cases worldwide and over 
1,103,791 deaths, in less than eight months.[4] In 
the United States alone, there are more than 7.19 
million cases and over 205,000 deaths.[5] In 
addition to the apparent threats the COVID-19 
poses to all individuals, one report from Italy 
suggested that this epidemic hide subtle menaces, 

like the “distraction effect,” that are particularly 
important for patients with cancer. The distraction 
effect for cancer patients may lead to diverting the 
attention exclusively to the COVID-19 situation and 
overshadowing the everyday clinical practice may 
have substantial negative implications, especially 
for cancer patients. [6] Considering not only the 
intersection of COVID-19 and cancer, in the United 
States we must consider the added risk of 
overlooking the ongoing and systematic health 
inequities faced by racial and ethnic minorities. 

COVID-19 in the United States 
Although China and Italy were differentially 
affected in the early stages of the pandemic, the 
United States now has more cases and more 
deaths than any other country. Inconsistent 
messages emanating from the President’s office at 
the federal level and from multiple governors at 
the state level have fostered confusion and 
heightened the potential of greater risks not only 
to those who are immune compromised but also 
to others in the community. Missteps such as a 
lack of a coordinated, systematic national 
approach, a failure to issue timely shelter-in-place 
orders, inadequate numbers of hospital ICU beds 
in NYC while they awaited the arrival of naval 
hospital ships, and individual disbelief, claiming 
that the virus was a hoax, slowed the receipt of 
essential resources, and likely have resulted in 
avoidable infections. [7] Compared to five other 
countries (i.e., China, South Korea, Italy, France, 
United Kingdom) one cannot help but question if 
the U.S.’s lagging response and hesitancy to 
escalate the stringency of its public policies might 
have saved lives. In April, states like New York and 
California, large metropolitan areas that have had 
high transmission rates, stay at home orders were 
announced and put in effect at earlier dates. The 
need to shelter-in place, mandated by some state 
governors, was designed to stem the tide of 



 
 
 
 
 

 
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community spread, with the hope that the need 
for emergency department and hospital 
admissions would flatten and result in slowed 
transmission In other less densely populated states 

that are predominately rural, like North Dakota, 
such mandates were not implemented [8]. 
(Figure 1). 

Figure 1. States with orders to stay home as of April 20) 

 
 
Racial and Ethnic Disparities Related to 
COVID-19 
While the nation strives to address the economic 
and social impacts of the COVID-19 pandemic, 
concerns related to the likelihood of overwhelming 
the healthcare system with crisis-related health 
care occurred in New York in the first phase of the 
virus, and are seemingly inevitable now as 
numbers surge currently in Texas, Arizona, and 
Florida. Economic impacts are being experienced 
as nearly 20% of the workforce faces 
unemployment, while hourly workers must grapple 
with basic survival and insufficiency due to lost 
wages and hunger, debt, and a need to care for 
children at home due to school and daycare 
closures. Social losses, equally staggering, continue 
to emanate from a loss of daily connections and 
livelihoods as well as ceremonial occasions that 
mark predictable achievements. Although many 

geographic regions have experienced differential 
impacts from COVID-19, there are stark disparities 
for several populations that have received little 
attention. One of the most alarming disparity 
trends is the high incidence of infection and the 
elevated mortality rate among ethnic/racial 
minorities, particularly African and Hispanic 
Americans compared to non-Hispanic Whites. [9] 
Reports of disparities in testing, access to care, and 
poor triage practices and decisions resulted in 
minority individuals being sent home because their 
symptoms were not severe. However, such cases 
extending beyond ethnic/racial minority 
populations appear to be more fatal in minority 
communities who already face significant barriers 
to adequate care. Adding to this detriment, many 
ethnic/racial minorities have existing chronic 
conditions superimposed on COVID-19 and this 
leads to progressive worsening of health and 



 
 
 
 
 

 
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eventual death from the coronavirus. For example, 
African Americans people are being infected and 
dying at higher rates in Chicago, New Orleans, 
Philadelphia, Detroit, Louisiana, and Milwaukee. [9, 
10] In Milwaukee, the life expectancy of African 
Americans is 14 years shorter, on average, 
compared to Whites. [11] By April 3, 2020, almost 
half of Milwaukee County’s 945 cases were African 
American and 81% of the 27 deaths occurred in a 
county whose African American population 
constituted 26% of residents. While African 
Americans make up 13% of the US population, 
they account for 23% of all deaths. As of May, the 
death rate for COVID-19 in Illinois was 34%, while 
they make up 15% of the population; Michigan 
41%, while they comprise 14% of the population; 
and Kansas 33% while they make up 6% of the 
population. In Chicago, where African Americans 
represent ~30% of the population they represent 
43.1 of COVID-19 deaths and 29.8% of all cases 
[12, 13] 

In addition, North Carolina and Connecticut are 
seeing the same disproportionate cases of deaths. 
[10, 14, 15] Moreover, collateral cases, such as that 
illustrated in the exemplars presented earlier, are 
not accounted for in the mortality rates. In April, 
the extent to which states report data by 
race/ethnicity varies: 2 states reported testing, 34 
states reported confirmed cases, and 26 states 
reported deaths and collected information on 
race/ethnicity.[15] By August, 6 states reported 
testing, 49 states reported confirmed cases, and 
46 states reported deaths and collected 
information on race/ethnicity,[15] yet not all states 
collect this data, thus, true epidemiological trends 
are limited. Failure to capture complete 
demographic data (1) ignores the hidden inequities 
in healthcare and public health, (2) perpetuates 
disparities and structural racism by failing to fully 
investigate and understand the health of a 
population of people, and (3) subsumes that race 

is an unimportant factor in the prevention, 
mitigation, and mortality from COVID-19. Some of 
the trends driving the curve in African American 
communities may include culturally-specific 
responses to endemic racism such as the 
communal mistrust, a high prevalence of risk 
factors that contribute to death with COVID-19 
(diabetes mellitus, high blood pressure, asthma, 
and immunocompromised), and the fact that 
African Americans are more likely to be essential 
workers with required physical presence. Black 
American men may be concerned about wearing 
face masks due to the stigma of being viewed as a 
criminal. Also, minority serving hospitals may not 
have the resources required for COVID-19 patients 
while more affluent hospital may limit care to low-
income patients. Well known among African 
Americans and as reported by researchers is that 
healthcare workers tend to interact differently with 
African Americans compared to other racial/ethnic 
groups. [16-20] 

The intersection of COVID-19 with cancer has led 
to further inequities. Research from two large 
healthcare systems in the Midwest found that 
cancer patients undergoing active treatment saw 
their risk for death increase 15-fold with a COVID-
19 diagnosis.[21] Specifically, among COVID-19 
patients with a history of cancer, an increased risk 
for death was seen for those ages 60 to 69 years 
(OR 6.3, 95% CI 1.1-35.3), 70 to 99 years (OR 18.2, 
95% CI 3.9-84.3), and those with a history of 
coagulopathy (OR 3.0, 95% CI 1.2-7.6).[22] In this 
same study of 2,186 US adults with invasive cancer 
and laboratory-confirmed SARS-CoV-2 infection, 
African American patients were approximately half 
as likely to receive remdesivir as white patients. 
Despite Black patients consisting of less than 10% 
of the total study population, Gadgeel noted that 
39.4% of COVID-19 diagnoses in the active cancer 
group were among African American patients, as 



 
 
 
 
 

 
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were a third of diagnoses in the cancer survivor 
group. 

Impacts of COVID-19 across the spectrum of 
cancer treatment 
In the United States, African Americans bear a 
disproportionate share of the cancer burden, 
having the highest death rate and the lowest 
survival rate of any racial or ethnic group for most 
cancers. [23] Key variables associated with this 
disparity results from a combination of social 
factors that influence exposure to racism, food 
deserts, and access to and receipt of appropriate 
healthcare. [9, 24] COVID-19 may further increase 
the burden in multiple ways across the cancer 
prevention and treatment spectrum. Severely 
immunosuppressed patients generally have a 
higher risk of developing complications in COVID 
infections. Thus, it should be assumed that cancer 
patients are at increased risk of a more severe 
course of COVID-19. [25] An early report from 
China indicated [20] a higher incidence of COVID 
in patients diagnosed with cancer [20]. In another 
report from China, of 2007 cases from 575 
hospitals of patients with cancer were observed to 
have a higher incidence of COVID, higher risk of 
severe events (a composite endpoint defined as 
the percentage of patients being admitted to the 
intensive care unit requiring invasive ventilation, or 
death) compared with patients without cancer. 
[26] Cancer survivors who have been treated with 
cardiotoxic chemotherapy may also be at higher 
risk for poor outcomes. [27] 

In addition to increased morbidity and mortality 
associated with COVID-19, cancer patients and 
individuals at risk for cancer have been adversely 
affected by the COVID-19 pandemic in several 
other ways. For patients in active treatment, one of 
the major risks is the inability to receive necessary 
medical services (both in terms of getting to 
hospital and provision of normal medical care 

once there) because of the outbreak. Guidance for 
prioritizing the use of radiotherapy and systemic 
treatments during the COVID-19 pandemic 
focuses on including diseases with an imminent 
risk of early mortality (such as acute leukemias) or 
substantial morbidities (such as spinal cord 
compression). [28] With a lack of PPE in 
combination with risk factors associated with 
COVID-19, cancer patients’ treatment plans were 
altered earlier in the pandemic with chemotherapy 
and radiation treatment plans delayed or 
modified. This is the result of the risk factors 
associated with COVID-19 as having cancer 
increases risk of contracting the virus, being 
hospitalized, being placed on a ventilator and 
death. [29] Another contributing factor of COVID-
19 risks is that cancer treatments suppress the 
immunity system of cancer patients. A delay in 
patient treatment minimizes potential immune 
suppressive treatments as well as risks of 
transmission at treatment sites. [30] Long-standing 
protocols for administration of chemotherapy and 
radiotherapy for lower or middle risk patients are 
being implemented differently during the 
pandemic, with different regimens suggested and 
potential delays in treatment. The excerpt below 
highlights the risk to an individual whose death 
may have been hastened by the COVID-19 triage. 

My sister-in-law died today. She survived 
breast cancer twice. The cancer wing was 
shutdown to make space for COVID-19 
patients. She was told that her treatments were 
going to be stopped. She died at home. She will 
not be included in the COVID death count. It 
makes the numbers look lower than they 
actually are. In the past three weeks, 3 people 
within my circle of friends have died, and now 
family member too ». (A. Lawson, personal 
communication. 16 April 2020). 



 
 
 
 
 

 
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Differential Effects on Racial and Ethnic 
Minorities with Cancer-related Pain 
Within the African American community, it is a 
well-known that African Americans who report 
symptoms of pain are not believed by the health 
care providers to the same extent as White 
patients. [16] Similar patterns are noted in patients 
with cancer pain. For example, having cancer 
and/or receiving chemotherapy may benefit 
minority populations because their complaints of 
new health concerns are likely to be taken more 
seriously. In contrast, individuals with cancer may 
be more susceptible to COVID-19 [31], and may 
experience pain symptoms in addition to cancer-
related pain and other non-malignant chronic 
pain. Further, these pain symptoms may not be 
taken as seriously given the immediate priorities to 
contain and mitigate the COVID infection. 
According to recently published pain guidelines, 
pain clinics should triage cancer-associated pain 
syndromes as an urgent priority. [32] Two general 
consensus statements on pain management have 
been published to guide care for all patients with 
COVID-19. [32, 33] The application of identified 
best practices must be applied consistently and 
equitably to ethnic/racial minorities. Telemedicine, 
though a novel solution to healthcare access, may 
not translate in ways that are beneficial to 
minorities. Some older racial/ethnic minorities or 
rural residents with cancer or their caregivers may 
lack access to the internet, have insufficient 
bandwidth, or lack smart devices, all of which are 
necessary for participating in telehealth visits or 
support groups. If we are to stem the tide of 
COVID-19 while ensuring patients have adequate 
pain relief, we must explore the roles of 
intersectionality and justice moving forward. 

Survivors 
Many cancer survivors are concerned and wonder 
how their cancer status affects potential COVID-19 

risks as individuals with underlining health 
conditions appear to be at higher risk for major 
complications [1]. The immunosuppressive effects 
of cancer treatment increases the risks for cancer 
patients and survivors. In a study of a cohort of 
1571 patients with COVID-19, 8 of whom had a 
prior history of cancer, patients with a history of 
cancer had a higher incidence of severe events – 
defined as the percentage of patients admitted to 
an intensive care unit requiring invasive ventilation, 
or death – compared with other patients. [34] 
Routine surveillance in patients considered to be at 
relatively low risk of recurrence, and those who are 
asymptomatic during the follow-up period were 
postponed during the early stages of the 
pandemic and rates of preventive appointments 
continue to lag. [35] This trend continues as the 
pandemic has progressed. Data from March 15 to 
June 16, 2020 show that 285,000 (breast), 95,000 
(colon), and 40,000 (cervical) exams were missed, 
which represent deficits of 63%, 64%, and 67% 
relative to the number of screenings in a prior year 

For the community at-large, it is unknown at this 
point how the delay in cancer screening 
examinations may affect future morbidity and 
mortality for individuals who have not yet received 
screening examinations in a timely manner. As 
quarantine restrictions are relaxed, planning for 
resuming screening to mitigate harms is an 
important aspect of cancer detection at early 
stages in at risk individuals. 

Increasing likelihood for Optimal Outcomes 
for Cancer Patients and individuals at 
Heightened Risk of Health Disparities 
Historically, many African American individuals 
distrust hospital-, university- and clinic- 
practitioners due to historical racism. Addressing 
racism will require a long-term commitment and a 
willingness to build partnerships. However, the 
onus rests with the medical community and the 



 
 
 
 
 

 
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governmental structures of the United States to 
demonstrate trustworthiness. [36] Building 
partnerships with local African American 
community organizations such as churches, 
initiating the delivery of forums, retreats, and other 
social events that are designed to enhance 
approachability and getting to know individuals on 
a more personal level are some of the venues that 
can be implemented to establish trustworthiness. 
We suggest convening gatekeeper-identified 
leadership groups, African American physicians, 
nurses, faith and civic leaders who are trusted by 
their communities and partnering with them to 
develop community-based print and media 
strategies that are responsive to their constituents. 
Seeking their insight and advice as to best 
practices for interacting with racial/ethnic 
minorities and those who suffer disparities are 
likely to be instrumental in building healthcare 
systems which are responsive to their socio-
cultural preferences and healthcare needs. 

Addressing health disparities in cancer treatment 
and outcomes so that treatment delays do not 
result in sentinel events must also be considered. 
Kutikov, Weinberg, Edelman and colleagues 
recommend that physicians must be mindful of 

increased vulnerability to potential adverse 
outcomes that may emanate from COVID-19 
following oncological surgery, systemic 
chemotherapy, or radiation therapy. [37] They 
recommend that differentiating treatment options 
based on cancer types. For example, they suggest 
that solid tumors arising from pancreatic or lung 
cancer as well acute leukemia require immediate 
diagnosis and treatment. However, early-stage 
cancers such as prostate and breast among others 
may not. [36] While weighing comorbidities, they 
recommend weighing the risk of progression with 
cancer care delay alongside the probably of 
significant morbidity. 

Telemedicine, an emerging approach to ensuring 
practitioner access, has the potential to mediate 
long wait times and ensure triaged care. Perhaps, 
following this pandemic, it will become a viable 
alternative to in-office visits, where appropriate. 
Overall increasing the likelihood of optimal 
outcomes could be addressed by enacting system 
level responses designed to foster practice and 
policy for cancer care equity, infection prevention 
and control, cancer pain management, and cancer 
palliative care (see Table1) 

 

Table 1. Recommendations for Practice and Policy for Cancer Care 

DOMAIN RECOMMENDATION 

Cancer Care Equity • All cancer care centers should develop and implement a standard, system-wide plan 
for cancer care equity. 

• Utilize multiple modalities, e.g., telehealth and traditional methods (phone and mail), to 
communicate and follow-up with patients. 

• Cancer care centers are encouraged to develop a helpline and/or online portal that 
allow patients a safe space to ask questions. 

• Ensure all patients have access to COVID-19 testing at cancer care centers or at-home, 
and maintain accurate documentation of positive cases for future data science work. 



 
 
 
 
 

 
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Infection Prevention 
and Control 

• Ensure all patients with cancer have access to necessary PPE. 

• Develop an emergency response plan with patients and provide education on how to 
utilize plan. 

• Convene gatekeeper-identified leadership groups within the African American 
community to provide factual information about COVID-19 and infection control. 

Cancer Pain 
Management 

• Ensure patients have a self-management pain treatment plan in place, in case palliative 
radiation or other clinic-based pain-relieving procedures are inaccessible. 

• Implement and/or adapt consensus-based COVID-19 pain management guidelines for 
patients with cancer. 

 
As a society, we must prepare for the toll that this 
pandemic has exerted on patients, families, and 
caregivers alike for African Americans, their 
families, and communities. The potential for 
traumatic impact among family members who lose 
loved ones without an opportunity to say 
goodbye, and among those who care for dying 
patients while family members say their goodbyes 
virtually, and express unremitting grief to those 
strangers who witnessed patients’ passages, must 
be recognized. Mental health practitioners must 
become prepared to treat and care for those who 
exhibit a sudden onset of depression, anxiety, 
hypervigilance, or other behaviors that impede 
their functionality or ability to resume the habits of 
daily living. Irrespective of the duration of 
symptomatology, the need for psychological care 
that is tailored to address acute and chronic 
mental health issues arising from the pandemic 
should be anticipated. 

Conclusion 
Despite efforts to reduce the unequal impacts 
being felt by minorities, generations of systemic 
disadvantage and inequality in healthcare and 
cancer care for communities of color have become 
amplified and made more urgent during the 
coronavirus crisis. Understanding the risks, 
intersection, and additive effect of COVID-19 in 
minority individuals with cancer is crucial. Ethnic 

and racial disparities already pervasive in our 
health care system coupled with COVID-19 and 
existing racial and ethnic disparities in cancer 
outcomes may lead to greater morbidity and 
mortality in existing at-risk groups. Unequal access 
to and use of healthcare and unequal access to 
treatment in the healthcare environment are a few 
of the factors that contribute to health disparities 
specifically for African Americans. It is imperative 
that the disparities gap does not widen as a result 
of the COVID-19 pandemic. 

ACKNOWLEDGEMENT 
This publication was made possible by funding 
from the National Cancer Institute of the National 
Institute of Health under the Partnership of the 
U54CA233444 (UF). Its contents are solely the 
responsibility of the authors and do not necessarily 
represent the official views of the NIH or NCI. The 
final peer-reviewed manuscript is subject to the 
NIH Public Access Policy. 

 
Conflicts of interest 
The authors declare no conflict of interest. 

Authors' contributions 
This manuscript was conceived by L.B.H. and D.E. 
L. L.B.H. and D.E.L. led the writing. All authors 
contributed to writing and editing the manuscript. 



 
 
 
 
 

 
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www.companyofscientists.com/index.php/chd e10 Cancer Health Disparities 

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https://www.uptodate.com/contents/coronavirus-disease-2019-covid-19-cancer-care-during-the-pandemic
https://www.uptodate.com/contents/coronavirus-disease-2019-covid-19-cancer-care-during-the-pandemic
https://www.uptodate.com/contents/coronavirus-disease-2019-covid-19-cancer-care-during-the-pandemic
https://www.asco.org/asco-coronavirus-information/care-individuals-cancer-during-covid-19
https://www.asco.org/asco-coronavirus-information/care-individuals-cancer-during-covid-19

	Introduction
	COVID-19 in the United States
	Racial and Ethnic Disparities Related to COVID-19
	Impacts of COVID-19 across the spectrum of cancer treatment
	Differential Effects on Racial and Ethnic Minorities with Cancer-related Pain
	Survivors
	Increasing likelihood for Optimal Outcomes for Cancer Patients and individuals at Heightened Risk of Health Disparities

	Conclusion
	ACKNOWLEDGEMENT
	Conflicts of interest
	Authors' contributions

